Medicare in Wisconsin

The Medicare program allows retirees over the age of 65 and adults with certain disabilities to receive health insurance backed by the federal government. From 2010 to 2020, the number of people enrolled in Medicare in Wisconsin rose by nearly 25%. As of 2020, there were almost 1.2 million Wisconsinites enrolled in Medicare. Of those, about 543,000 chose a Medicare Advantage plan.

Advantage plans are growing in popularity. While Original Medicare enrollment numbers are almost unchanged over the last decade, the number of enrollees choosing an Advantage plan has nearly doubled. If future enrollments follow the current pattern, more people will choose to enroll in Medicare Advantage than Original Medicare by the end of this decade.

Original Medicare is separated into two parts: Part A and Part B. Part A is offered free of charge to anyone who’s contributed to Medicare for a set amount of time in their career. It covers medical expenses related to inpatient care, such as emergency room visits, hospital care, skilled nursing care and some home health services. Part B covers outpatient medical procedures, routine checkups, diagnostic examinations, medical equipment and non-emergency medical transportation. In 2022, the premium for Part B costs $170.10 per month. 

Medicare Part D offers prescription drug coverage, and premiums vary based on the level of coverage people choose. Medicare Advantage plans, also known as Medicare Part C, are privately administered insurance plans subsidized by the government, and they provide all the benefits covered by Parts A and B. Most Advantage plans also include prescription drugs (plan D). The difference is that Medicare Advantage enrollees can customize their coverage and add benefits not covered under Original Medicare. Medicare Supplement plans can cover some of the out-of-pocket expenses Original Medicare enrollees need to pay. 

This guide provides an overview of these programs and the resources available to help seniors customize their coverage and make more informed choices about their health care. 

Options for Medicare Coverage in Wisconsin

Original Medicare offers basic coverage that every senior needs, but more people are exploring ways to add coverage that’s more suited to their needs. Wisconsinites have a few options for creating custom coverage and don’t need to depend solely on the normal Medicare program for their medical needs. They may find alternative plans through private insurance companies serving the state. 

Original Medicare (Parts A & B)

Original Medicare is administered by the Centers for Medicare & Medicaid Services (CMS) and is open to seniors aged 65 and over, along with those under 65 years old, but with certain disabilities or end-stage kidney disease. It includes two parts. Part A covers inpatient hospital care, nursing home and skilled nursing care, hospice and home health care. Part B, or medical coverage, pays for medically necessary goods and services such as durable medical equipment, mental health services and emergency medical transportation. 

Unlike most private Medicare plans, Original Medicare’s provider network isn’t limited to the beneficiary’s geographic region, making it easier to obtain services while traveling within the country. In most cases, Medicare doesn’t pay for health services the individual receives outside the United States. 

Under this program, seniors pay for services as they receive them. They must pay an annual deductible, which is $1,556 for Part A and $233 for Part B in 2022. After they’ve paid this amount, Medicare covers all eligible services at 80%. Beneficiaries pay the remaining 20% out of pocket.

Who Should Consider Original Medicare

Original Medicare may be a good option for those who:

• Travel frequently within the United States
• Don’t need extra benefits such as home-delivered meals and coverage for over-the-counter medication
• Want to choose their own prescription drug coverage

Medicare Advantage (Part C)

Medicare Advantage is an alternative to regular Medicare coverage. Private insurance companies offer and administer Advantage plans and are legally bound to provide the same coverage as Medicare Part A and Part B, with the exception of hospice care which remains covered under Medicare Part A. Some of the benefits enrollees can add through an Advantage plan include vision and dental coverage, prescription drug coverage and savings programs that cover the cost of health club memberships and other wellness services. Advantage plans also have limits on annual out-of-pocket expenses.

Advantage plans are broken down into four categories: Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Private Fee For Service (PFFS) and Special Needs Plans (SNP). Details such as who’s eligible, premiums, deductibles, networks and what expenses enrollees are responsible for vary and might not be the same for different plans or insurance companies. 

Who Should Consider Medicare Advantage

Those who could benefit most from an Advantage plan include:

• People who want more flexibility with out-of-pocket expenses
• People who need vision or dental coverage
• Seniors who are generally healthy , so may benefit from lower premiums
• Those who don’t mind receiving care from network providers

The Top 10 Medicare Advantage Plans in Wisconsin

There are 115 Medicare Advantage plans to choose from in Wisconsin in 2022. With so many choices, seniors may find the process of reviewing insurance companies daunting. This table reviews the top 10 Advantage providers (by enrollment across all plans for each provider) and the range of costs for each as of April 2022. 

Medicare Prescription Drug Coverage (Part D)

Original Medicare doesn’t pay for most prescription drugs through Part A or B coverage. Instead, seniors purchase separate prescription drug policies, also called Part D coverage. Medicare contracts with private health insurance companies to provide this coverage. There are multiple plans to choose from with varying monthly premiums, which beneficiaries pay in addition to their Original Medicare premiums. While seniors don’t have to purchase prescription drug coverage when they’re first eligible for Medicare, not obtaining this coverage at this time may result in late enrollment penalties they pay for as long as they have Medicare if they enroll later.

Each prescription drug plan has its own formulary, or list of covered drugs. Formularies are typically split up into tiers. The tier a medication is in determines how much the insurance company pays and how much the beneficiary pays for it. Lower-level tiers are usually made up of generic and low-cost brand name drugs, while higher tiers are composed of more expensive brand name and specialty drugs. In most cases, the lower the tier, the lower the policyholder’s cost-sharing responsibility.

Who Should Consider Medicare Prescription Drug Coverage

Seniors who may benefit from prescription drug coverage include those who:

• Currently take prescription medication or expect to in the future
• Want to avoid late enrollment penalties
• Want to reduce out-of-pocket prescription drug expenses

Medicare Supplement Insurance (Medigap)

While Original Medicare provides coverage for many medical costs, seniors may still have significant out-of-pocket expenses. These may include copays, coinsurance and deductibles. Seniors may be able to reduce their cost-sharing obligations by purchasing a Medigap plan. These plans can only be used with Original Medicare. It’s illegal for private insurance companies to sell Medigap plans to those with Medicare Advantage plans.

For more information on Medigap plans, seniors can refer to the Best Medicare Supplement Companies of 2022 page.

Who Should Consider Medicare Supplement Insurance

Good candidates for Medigap may be those who:

• Have ongoing health issues and expenses
• Travel overseas often
• Want to access an expanded network of health care providers
• Expect to need health services not covered by Original Medicare

Medicare Resources in Wisconsin

With so many choices for residents looking for affordable coverage that meets their individual needs, building the right plan can be time-consuming, confusing and frustrating. Fortunately, resources are available to help people review their coverage options, apply for benefits and understand their policies. These organizations offer assistance on both the federal and state levels and may provide counseling in person or virtually.